The Quality Management Coordinator owns Horizon Recovery’s Quality Management and Compliance Program. This is the Joint Commission-required Quality Management function, combined internally with compliance ownership, so that one role is accountable for standards, safety, investigations, privacy, and outcomes across all programs and locations.
While the title reflects Horizon Recovery’s current organizational size, the functional scope of this role mirrors a Director of Compliance in a larger health system. The Coordinator is responsible for the compliance calendar, internal investigations, root cause analyses, corrective actions, plans of correction, mandatory reporting, HIPAA Privacy Officer responsibilities, performance improvement, and program-level reporting to leadership.
This role is intentionally designed as a coach and collaborator — not an internal auditor. The Coordinator provides practical support, tools, and guidance to help teams succeed while never compromising on standards. When gaps are identified, the Coordinator communicates them clearly, recommends workable solutions, and tracks follow-through. Enforcement and operational implementation of corrective actions are led by the Chief Operating Officer.
Regulatory Designations
- Designated HIPAA Privacy Officer for Horizon Recovery.
- Designated 42 CFR Part 2 Records Custodian for substance use disorder patient records.
Job Duties / Responsibilities / Essential Functions
The following outlines the decision rights and accountability boundaries for this role and the leadership positions it partners with most closely:
- Quality Management Coordinator: Owns the Quality Management and Compliance Program. Conducts audits, tracers, investigations, root cause analyses, and performance improvement activities. Drafts plans of correction and mandatory reports; submits after CEO/COO review and approval. Designated HIPAA Privacy Officer and 42 CFR Part 2 Records Custodian. Does not enforce discipline or unilaterally implement operational change.
- Chief Operating Officer: Leads enforcement and operational implementation of corrective actions across departments. Reviews and approves plans of correction and mandatory reports prior to submission.
- CEO: Sponsors and supports the Coordinator’s findings. Serves as primary strategic external liaison to regulators and accrediting bodies. Reviews and approves plans of correction, mandatory reports, and external communications prior to submission.
- Human Resources: Partners with the Coordinator on investigations that involve staff discipline or personnel action. HR leads disciplinary matters; the Coordinator leads the compliance and regulatory aspects.
This role does not enforce discipline, unilaterally implement operational change, manage external licensing relationships, or own staff-discipline outcomes. These responsibilities remain with the COO, CEO, and HR respectively.
1. Quality Management Program (TJC-Required Function)
- Design and maintain Horizon Recovery’s Quality Management function in accordance with The Joint Commission Performance Improvement requirements.
- Collect, compile, and analyze data on outcome and process measures to monitor organizational performance.
- Identify trends, variation, and opportunities for improvement; recommend and coordinate performance improvement initiatives.
- Facilitate root cause analyses (RCAs) for sentinel events and serious incidents; document findings and track actions to closure.
- Support leadership in establishing measurable quality goals and monitoring sustained improvement over time.
2. Compliance Program Operations
- Own the organizational compliance calendar — including internal audits, tracers, drills, and reviews — and keep evidence organized, current, and retrievable.
- Conduct collaborative internal audits and mock tracers across medication services, environment of care/life safety, privileging/competency, training records, and incident reporting; provide coaching and job aids to teams.
- Facilitate corrective-action planning including root cause identification, action steps, owners, and timelines; track to closure; re-audit to verify sustained effectiveness; escalate overdue or ineffective items to the COO and CEO.
- Maintain continuous internal survey readiness including eBinders, document rooms, spot checks, required postings, and compliance logs.
3. Policy, Standards & Coaching
- Maintain the policy and procedure lifecycle including version control, approvals, “Last Reviewed / Last Revised” dating, and staff attestation.
- Translate ADHS and Joint Commission standards into clear procedures, checklists, job aids, and coaching resources that frontline teams can apply in daily workflows.
- Monitor regulatory and standards updates; partner with operations leaders and the Operations Training Coordinator to embed changes into practice without disrupting care.
4. Investigations
- Own end-to-end investigations of complaints, grievances, ethics reports, compliance concerns, and HIPAA/42 CFR Part 2 privacy breaches or near-breaches.
- Conduct intake, interviews, evidence review, analysis, and production of written findings and recommendations.
- Partner with Human Resources on any investigation that intersects with staff discipline or personnel action — HR leads the disciplinary aspect; the Coordinator leads the compliance and regulatory aspect.
- Maintain investigation records and chain of custody in accordance with regulatory and legal requirements.
5. Incident Management & Mandatory External Reporting
- Own the internal incident and event process: intake, categorization, trend analysis, and mitigation follow-through.
- File timely mandatory reportable incident reports to ADHS, DCS, and The Joint Commission per regulation and policy, following CEO/COO review where required; maintain filing logs, timestamps, confirmations, and supporting evidence.
- Elevate complex or borderline reportability determinations to the CEO and COO before filing.
- Protect confidentiality in accordance with HIPAA and 42 CFR Part 2 throughout all reporting activities.
6. Plans of Correction
- Draft plans of correction in response to survey findings, deficiencies, or regulatory concerns.
- Coordinate with impacted departments to establish root cause, corrective actions, responsible owners, and implementation timelines.
- Submit plans of correction following CEO/COO review and approval; track implementation and monitor for sustained effectiveness.
7. Privacy & Confidentiality – HIPAA Privacy Officer / 42 CFR Part 2 Records Custodian
- Serve as Horizon Recovery’s designated HIPAA Privacy Officer and 42 CFR Part 2 Records Custodian.
- Maintain privacy policies, Notice of Privacy Practices, consents, authorizations, and disclosure logs.
- Conduct privacy risk assessments and periodic audits of PHI access; address findings through corrective action.
- Respond to privacy complaints, conduct breach risk assessments, and coordinate required breach notifications.
- Partner with the Operations Training Coordinator to deliver privacy and confidentiality training to all staff.
8. Reporting & Analytics to Leadership
- Prepare regular Quality Management and Compliance reports for the CEO, COO, and organizational leadership.
- Maintain a compliance and quality risk register with current mitigation status.
- Support quality and compliance committee activities as assigned, including agenda preparation, minutes, and follow-through on committee actions.
9. Documentation, Systems & Administrative Coordination
- Maintain organized evidence-of-compliance repositories including policies, logs, rosters, audits, corrective action plans, plans of correction, investigations, and privacy records.
- Use data tools such as Microsoft Excel or Google Sheets to track trends and demonstrate improvement over time.
- Coordinate with dedicated administrative support for deadline tracking, scheduling, audit and tracer coordination, calendars, minutes, eBinder assembly, and evidence uploads.
Competencies / Skills / Knowledge / Experience
- Quality & Safety Mindset: Designs controls that reduce risk and improve outcomes; approaches work with a genuine commitment to patient and organizational safety.
- Coaching & Influence: Builds capacity across teams; partners to solve problems and sustain change without relying on direct authority.
- Regulatory Fluency: Accurately interprets ADHS and Joint Commission requirements and translates them into practical, doable workflows.
- Investigative Rigor: Conducts thorough, fair, and well-documented investigations from intake through final findings and recommendations.
- Courageous Integrity: Never compromises on standards; addresses subpar work and compliance gaps promptly and professionally.
- Operational Rigor: Builds reliable audit systems, tracks gaps to closure, verifies sustained effectiveness, and escalates appropriately — without overstepping enforcement boundaries.
- Systems Thinking: Harmonizes processes, documentation, and compliance activities across programs and multiple sites.
- Ethics & Confidentiality: Handles sensitive information, investigations, and privacy matters with integrity and full regulatory compliance.
Supervisory Responsibilities
This position has no direct supervisory responsibilities. The Quality Management Coordinator works across all departments in a coaching and advisory capacity and is expected to influence outcomes through expertise, relationship, and documented findings rather than direct authority over staff.
Minimum Qualifications
- Minimum 1–3 years of experience in healthcare compliance, quality management, accreditation, or regulatory affairs.
- Working knowledge of ADHS/DHS licensing rules and The Joint Commission standards applicable to behavioral health programs.
- Demonstrated experience with internal audits, tracers, investigations, corrective action coordination, and root cause analysis.
- Working knowledge of HIPAA and familiarity with 42 CFR Part 2 requirements.
- Strong analytical skills; comfort with data, measurement, and performance trend analysis.
- Excellent written communication skills; ability to produce clear reports, investigation findings, and plans of correction.
- Proficiency with Microsoft 365 and/or Google Workspace and document management platforms.
- Proven coaching, facilitation, and consultative skills with frontline staff and organizational leaders.
- Arizona Level One Fingerprint Clearance Card required (or ability to obtain prior to start).
- Ability to pass a pre-employment background check.
Preferred Qualifications:
- 3–5+ years of experience in healthcare compliance, quality management, accreditation, or regulatory affairs.
- Master-level knowledge of ADHS/DHS licensing rules and Joint Commission standards specific to adolescent behavioral health.
- Experience in a behavioral health setting, particularly adolescent behavioral health.
- Certified Professional in Healthcare Quality (CPHQ) or equivalent credential.
- Prior experience serving as a HIPAA Privacy Officer and/or 42 CFR Part 2 Records Custodian.
- Prior experience preparing for or participating in a Joint Commission survey or ADHS licensing inspection.
- Experience drafting and submitting plans of correction.
- Experience leading investigations including HIPAA and 42 CFR Part 2 breach risk assessments.
Physical Demands / Work Environment
The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
- Hybrid schedule combining on-site presence at Horizon Recovery facilities with remote work.
- Must be able to walk units, climb stairs, and inspect environment-of-care conditions across residential and clinic locations.
- Prolonged periods working at a computer.
- Must be able to lift and carry up to 30 pounds.
- Reliable high-speed internet connection and a professional workspace when working from home.
- Reliable transportation for occasional travel between program sites.
- Work takes place in behavioral health settings that serve adolescents and young adults; potential exposure to emotionally dysregulated clients.
Equal Opportunity Statement
Horizon Recovery is an equal opportunity employer. We consider all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other protected class. We are committed to a workplace that reflects the communities and families we serve.
Horizon Recovery is an at-will employer. This job description is not intended to be all-inclusive; an employee will also perform other reasonably related business duties as assigned by immediate manager or other management as required. Horizon Recovery reserves the right to revise or change job duties as the need arises. This job description does not constitute a written or implied contract of employment.
